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Monday, July 21, 2014

Faxed Refill Requests

Prescribers have been sending us Cease and Desist letters for some time requesting we stop all automated refill requests.
I laugh at them.
I write love notes on them and send them back.

Let us take a step back.
When you receive unsolicited mail, magazines, coupons, etc, what do you do?
When you receive spam what do you do? (Eat it while singing the Viking chant, duh!)
Do you reply to all the companies, email addresses, etc begging to be removed from their list?
(I know you can go online to cut down junk mail. So not the point here.)
Most people, I assume, simply throw the junk mail in the trash or recycling receptacle.
Spam/Junk emails? I'm guessing they get deleted en masse when clearing that folder.

Step forward now to the offices.
Anyone dealing with HIPAA must have a designated trash can for this type of trash.
Why would offices choose to write nasty notes on our correspondence, fax it back to us along with our refill requests, all but screaming "we no longer accept faxes."?

I Don't Care.
Our policy states we fax refill requests.
Your policy states you don't accept them.
Can we safely assume then that you have posted this policy for all of your patients to see?
In a conspicuous location?
Perhaps mailed to them notifying them of your policy?

Here is what I received last week:

Office Fax: We no longer accept fax refill requests. Must call.
CP Fax: We don't call. We fax. Is it safe to assume you notified the patient of this policy?
OF: We don't call our patients for refills.

This week I started something new for phun.
Office Fax: Call to schedule appointment.
CP: We scheduled patient for a 10:15 appointment tomorrow. We called the patient for you. Don't worry, we told her to arrive 15 minutes early.

Friday, July 18, 2014

What's in a Name?

A rose by any other name, would...be called something else. But how would I know what to expect when I saw it? When pharmacy staff answer the phone, they have long, boring scripts that no one really enunciates and no one really listens to anyway. I wish corporate would do away with the advertising during phone answering. However, I do like the part where we tell you who is answering the phone. In this case, we know what to expect from whom.
Hi. Thank you for calling CP Pharmacy. My name is CP and I am a pharmacist. How may I help you?
Thank you for calling, this is Leia Organa and I am an Uber-Tech. How may I help you?

We know what to expect. If I need a pharmacist for a transfer or something else professional, I ask for her. If not, then LO is perfect for me.
Where the hell are you going with this, CP?

Prescribers' offices do not answer the phone this way. They all answer it with "Dr. Zoffis. Hold!". Then when they come back we get "Dr. Zoffis. How may I help you?".
With whom are we speaking?
More importantly, what is the title of the person answering the phone? Secretary? Nurse? Doctor's Wife? Daughter? Cleaning Lady?
How do I know if you are going to be able to answer the specific question I have? If I give you my entire spiel, only to find out you are the filing clerk and have to transfer me to someone else, I just wasted my time and yours.
Is it too much to ask for name, rank, and serial number?

Thursday, July 17, 2014

A Snapshot...

People like to judge a situation based on a split second view. People like to make assumptions based on a still moment in time.
I am humbled by the number of people who read and comment on this page. I am often amazed at the comments people like to make, often negative and from non-pharmacists, on a single post they happened to stumble upon on a friend of a friend's page. It is a single post. I would like to extend an invitation to those of you to take a walk through time and go back to the beginning of this page. You will see a common theme from its inception. I beseech you. I implore you to take a long look at the content of this page before casting your aspersions on us. You probably complain about the wait times at your pharmacy too.

As an exercise, I invite you to walk into your pharmacy and take a picture. Take one snapshot at 9am. Or noon. Or 5pm. Take it home and examine it.
What's going on?
Are they busy?
How many people are on the phone?
Are engaged with a patient?
How many are just standing around?
How many are "putting pills in a bottle"?
Or just "slapping labels on stuff"?
Is there inventory to be put away?
Can you hear the phones ringing in the picture?
How many prescriptions are on the fax machine?
Or in the e-script queue?
How many people are in line to drop off?
To pick up?
Or in the waiting room?
How many are in line for shots?
How many are waiting for a pharmacist consultation?
Can you see if someone is on break and not in the pharmacy?
Can you see some creepy person staring at the staff trying to will his prescriptions to be filled faster?
Or someone with a camera trying out this simple, thought-provoking experiment?

The point is this: at any given moment in time, things are never as simple or complex as they appear. Making mass generalizations about a single post, or a single split-second in time is both narrow-minded and reflexive. Think before you make a judgement. Get to know me before you hate me.

Wednesday, July 16, 2014

Car Buying or If the Real World Worked the Way People Think Pharmacy Does

...or How Pharmacy Customer Service Destroyed Basic Human Self-Sufficiency...

Prescriptions are expensive. Replacement car parts are expensive.
Bought a new car last week. The lovely sales person rode with me on the test drive, showing me all the features the vehicle possessed. After purchase, I was given the grand tour and explanation of how everything worked and was sent on my way after saying I had no further questions for the salesperson.

I was driving around a week later and heard an awful sound.
I was not prepared for this.
This was not on the guided tour.
This was not a detail I remembered.
Rather than call someone, I continued my drive.
Then the car slowed and eventually rolled to a stop.
I immediately phoned my dealership and yelled at them. I found out my car had run out of gas. My word, why did no one explain this? No one told me it needed to be refilled. No one told me how to refill my vehicle. I am going to sue this dealership. I thought since it already had gas in it, I could drive until my dealership called to remind me to refuel. That's what my pharmacy does. They tell me when my bottle is empty. They call and tell me when to pick up my prescriptions. They take my pills for me and go to my appointments for me.

My pharmacy is the reason I am a bilge water filtering mollusk on the hull of society with no aspirations other than to have everything brought to me. If it were not for pharmacy and their "customer service" mantra I may have been able to get through life doing things for myself. Now I no longer can.
It's also their fault I am bankrupt.
I thought as long as I had checks in my checkbook, I could keep writing them.
My bank said otherwise.

Thank you for nothing pharmacy.

Tuesday, July 15, 2014

Trifecta of Trouble

Holiday Miracle this weekend.
Woman received a few pills until her backordered medication would be in stock. On the 28th day she returned to my pharmacy. Expecting them to be here, she was surprised that, despite repeated phone calls, they were returned to stock.
Her: Why didn't you tell me to come back sooner?
Me: The reason we only give you 2 or 3 or 4 pills is so that when they run out, you will be forced to return to get them by the fact that you are out.
Her: But I didn't run out.
Me: No? How did you make a few pills last you for a month?
Her: I had a surplus.
Me: That's one hell of a stash. Were you a prepper? A hoarder? A religious figure who can turn a few loaves and fishes into a magnificent feast for an entire town?
(Quote of the week nomination #1) Her: You don't really expect me to remember to take my medication every single day, do you?
Me: Yes. That's really the point. They don't really work if you don't really take them.

Her daughter then piped in that she was a former technician and she knew what I was saying but that I was wrong because I didn't tell her to come back in sooner.
Me: So I'm her babysitter now too?
Daughter: You should have put it on the label. (remember this statement)
Me: We did.
(Quote of the week nomination #2) Daughter: You expect your patients to actually read their labels every time they take their medications?
Me: So you're calling my patients stupid? Yes. How else are they to know what they are taking? If they are taking it correctly? Again, that's really the point.

They then drove down the street to transfer the medications to another fine establishment. There, they asked the polite pharmacist if their company offered a type of predictive refill program. She was told they did and it works just as ours does. However, it only works if you actually pick up your medication when it calls you, read your labels when you take your medication, and actually take them every single day as prescribed.

E-Rx Questions

The software a company uses is designed to simplify everyone's jobs. However, it is ultimately only as good as the humans who are using it. You would think with something as critical as electronic-prescribing, the Board-approved companies would have to use better software.
In my pharmacy experiences, pharmacy computers can be pretty smart. If we select a drug and the dosage form is capsules, when we select a sig (directions) from the menu or we type the short code "1bid", the computer is smart enough to translate that into "take 1 capsule by mouth two(2) times a day. If we enter 60 capsules to be dispensed, the computer, usually, will calculate this prescription to have a 30 day supply.
Back to e-Rxs. Why can't they all be smarter? The systems should be set up to not allow you to mix-and-match drugs with salt forms and strength combinations that do not exist. There should be some type of warning that the directions do not match. If I were to design this system, and seriously, they should be required to have pharmacists design and install these systems, I would take out much of the human factor. Keep in mind, most of the errors we see are ones we would never see with a hard copy hand-written by a physician. These are errors that only occur when selecting items from a drop-down menu.

There should be a drop down box for the drug. Once it is selected, there should be one for the strength. This one should only give you options for strengths that match the drug you selected. If the drug you selected does not come in a certain strength, you should not be allowed to enter it. Two errors we saw in the last week:
1. Gabapentin 200mg. It does not come in this strength in an oral dosage form for retail pharmacy.
2. Diclofenac Potassium 75mg. This version is only available as a 25mg or 50mg dose. The 75mg strength is only available as Diclofenac Sodium. The doctor probably knew what he wanted but it wasn't clear so we had to call. But I received this Rx at 6pm on Saturday. No one called back...
The other problem with this issue is what do we do when the doctor only selects "Diclofenac 50mg"? That is available as both salt forms, potassium and sodium. Which did he want? The computer should force him to pick one first, then only present him with the strengths that match. Fewer errors.

Directions: Something has to be done about these too. How many times do we get prescriptions where the directions make no sense, regardless of the drug?
1. Take non-specified once a day.
2. Take one(1) tablet by mouth with the first meal of the day, every morning twice a day (bid).
I have seen doctors select injectables or oral powder dosage forms then select directions for oral tablets or capsules. I have seen them order suppositories with oral directions. Once they have selected a drug, the route of administration should default in the directions. This way, when he only sees IM or SC, or PR, and he wanted Potassium 10mEq capsules PO, he can see something is amiss. Hopefully.

If your software is calculating the day supply for you, it should force you to enter a quantity. How many e-Rxs have we received with "N/A" in the quantity field? Why isn't the computer forcing them to enter an amount to be dispensed? But somehow the field immediately after is populated with "90 day supply". There is also a box to be checked for dosage form. Don't even get me started on the mess created by inhaler and insulin prescriptions...

Thursday, July 10, 2014

Doctors and Laws Part 2

I can just see this happening in the wake of the reclassification of Tramadol as a DEA Controlled Substance.

For example...
There are only a handful of e-script software programs approved by my State Board for sending controlled prescriptions electronically. Some offices route them via fax with an electronic signature or no signature with a note (electronic signature on file). This is not legal. Despite repeated phone calls to the offending offices, we continue to receive these on a daily basis. The funny thing, or sad thing, is that when my State Pharmacy Board pays me a visit, I could be fined $10,000 PER RX filled if I don't call on them. What happens to the prescriber if I fill these to help my patients who are in need? Nothing. Absolutely no consequences for them. Their patient has a prescription sent to my pharmacy, I call and the office is closed. Doctor cannot be paged. Patient comes in and I have a choice. My license is on the line but the doctor? Not his problem. 
Anyone else have a problem with this disparity?

Back to the offending office...I finally reached my breaking point when I received 7 controlled faxes from 7-8pm one night. I called the office:

Evil Empire Lady: So tell me what you want, what you really really want.
CP: I'll tell you what I want, what I really really want...I want your prescribers to put a wet ink signature on their controlled prescriptions before faxing them to me. They are aware this is illegal, right? 
EEL: "Yes. They are fully aware. They just don't care." (actual quote)
CP: How many calls do you receive from pharmacists on a daily basis about this?
EEL: "A couple dozen."
CP: A couple dozen? A day? 
EEL: Yep. 

So I called the DEA and State Board...no more problems. But why? Why do I have to fight them? Laws are laws. Rules are rules. Until we fight back and just say piss off, prescribers will continue to place the onus of writing correct prescriptions on us. Send them back. 

Doctors and Laws Part 1

Laws change. We have to adapt. We get a notice they are changing, a grace period to adjust, then we are expected to be completely compliant...unless you are a prescriber.
Despite ample warning that Hydrocodone strengths would be changing effective 1/1/2014, we continue to see prescriptions written incorrectly. So we call. And prescribers say "yeah I know I just forgot". And there are no consequences to "I forgot".
There need to be consequences.
There need to be fines.
There needs to be something in place to take the burden from the shoulders of the pharmacist who fills the prescription:

For example: I received a prescription from a pain clinic; a place of all places that should be on top of its game and know better. I received a bad prescription and left the following voicemail:

CP: This is CP calling to verify a prescription Doctor Zoffis wrote for a patient. He wrote Vicodin 5/325 and that would be Norco...unless he really wanted the New Vicodin which would be 5/300. Please let the doctor know that it IS July. There were memos sent to all pharmacies, and I would assume prescribers, in both November of 2012 and November of 2013 notifying and reminding them of these big changes that took effect January 2014...some 6 months ago. He really should know how to do this by now and I would greatly appreciate it if he would get with the program so I no longer have to waste my time or the patient's time standing around making phone calls because Herr Doctor neglected to read the memo. Thank You...

A few hours later, no rush right?, I get the privilege of the following phone call:

Dr. Zoffis' Nurse: Calling you back on the message you left earlier.
CP: Okay. Took long enough after I said the patient was waiting, but no bother. Whatcha got?
DZN: "The doctor appreciates the 5 minute message you left reminding him about this. He said he did read all the material sent last year about this." (actual quote)
CP: So you're saying that he READ the memo, he just couldn't INTERPRET the memo? Or what an impact it would have on his prescribing habits?
DZN: Yes. I'll tell him your concerns.
CP: Please do. While you're at it, could you also tell him that Tramadol will be a control soon as well. He should have received a memo on that too.
DZN: "Yeah. You'll probably be calling on that too." (again, actual quote)
CP: Yep. Because you can't train a doctor. They can read, but it doesn't mean it sticks.